Arthritis:
What It Is, Why You Get It, and How to Stop the Pain

They are the chorus line of the evening news, the
pinups of Modern Maturity: senior citizens in perpetual motion,
heedless of arthritic knees, hips and shoulders, dancing, jogging
and bicycling their way through a world populated exclusively by
gleeful grandparents and adoring toddlers.

THEY
ARE, OF COURSE, fictitious. Bee Jay Janiga, 73, is a real person
with arthritis and, like the ones in the commercials, she takes
one of the new class of drugs known as Cox-2 inhibitors. She dances,
tooin fact, shes been a professional since she began
performing at the age of 14, and she still leads a touring dance
troupe, the Racquettes (minimum age: 50).

What
she doesnt do is climb stairs, walk her dog or attempt to
sit still for the length of a concert. You put a smile on
your face and you perform, she says of the uneasy relationship
between her art and her aching knees. She isnt complainingbut
she isnt exactly celebrating, either.

BITTER
BATTLE
The twingeless grandparents of the TV ads are the shock troops in
one of the bitterest marketing battles of the year, pitting the
makers of Celebrex and Vioxxtwo breakthrough anti-arthritis
drugsagainst both older medications and each other. Last week
the battle took on a new intensity when a leading cardiologist reported
that the two drugs could pose a small but disturbing additional
risk of heart attacka connection that the drugs manufacturers
said was taken out of context. There are a lot of holes in
this drug class that havent been tackled yet, says the
author of the study, Dr. Eric Topol of the Cleveland Clinic. But
from watching TV youd think youd be dancing in the street.
The subject is of intense interest to the roughly 21 million Americans
with osteoarthritis, suffering joint pain that ranges from the annoying
to the crippling.

Dr.
John Klippel, medical director of the Arthritis Foundation, expects
that figure to rise to about 30 million by 2020, when the entire
baby-boom generation will have passed 55. For them, the question
is whether their future will be like the fictitious Ann
in the Celebrex commercial who doesnt let arthritis interfere
with her tai chi classesor more like Janiga, who dreads the
day when she will be driven to the extreme step of surgical replacement
of her knee joints, buying probable relief from pain at the certain
price of ending her dancing career forever.

She
faces such a stark choice because osteoarthritis, a disorder seemingly
as straightforward as a rusty hinge, is in fact a dauntingly complex
and intractable problem. Medicine offers either palliative pain
relief or radical surgery, but almost nothing in between that can
reliably alter the course of the diseasealthough exercise,
weight loss and dietary supplements such as glucosamine and chondroitin
all have shown promise in treating the symptoms, and hucksters have
been happy to fill the therapeutic void with strap-on magnets and
copper bracelets.

NO
RELIABLE MEASURE
The field is still searching for a biomarkera chemical substance
whose presence can serve as a reliable measure of the progress of
the disease, or of treatment. That is a particular problem because
the pain of arthritis is so subjective and variable, changing from
day to day for no apparent reason. Last month the National Institutes
of Health joined with four pharmaceutical companies to look for
such biomarkers. This was sort of a scientifically sleepy
disease until maybe about seven or eight years ago, says Dr.
David Felson of Boston University. We finally woke up and
said we have to put more resources into it because its such
a prevalent, disabling problem.

But
for drug companies, arthritis has been a boon: a nonfatal, incurable
disease that may require patients to take pain-relief medication
every day for decades. This explains the phenomenal success of Celebrex
and Vioxx. Since their introduction in 1999 the two drugs have captured
more than 60 percent of the $6.6 billion arthritis-drug marketa
figure that doesnt even include products like acetaminophen,
which are used to treat other conditions as well. They were promoted
remorselessly on televisiona little too remorselessly for
the Food and Drug Administration, which ordered the manufacturer
of Celebrex (Searle, which is now part of Pharmacia) to tone down
commercials that overstate[s] the efficacy of the drug.
The company obligingly changed the tag line on its jingleto
Come on and celebrate from the somewhat more specific
Do what you want to do.

The
advertising tended to obscure the fact that the two drugs basically
have the same effect as any number of existing medications, including
aspirinthat is, they relieve pain and reduce inflammation.
The reality is that these drugs have been tested against aspirin
and found to be equivalent, says Dr. Harvinder Luthra, head
of rheumatology at the Mayo Clinic. Dr. Roland Moskowitz, president-elect
of the Osteoarthritis Research Society International, believes that
the first line of treatment for mild to moderate arthritis pain
is exercise and over-the-counter analgesics such as acetaminophen,
followed by the class of drugs known as NSAIDs (for nonsteroidal
anti-inflammatory drugs): ibuprofen, naproxen, piroxicam and
diclofenac. These work by blocking the production of prostaglandins,
hormonelike substances that trigger inflammation. But prostaglandins
also control the secretion of gastric juices and the mucus that
lines the stomachwhich is why prolonged use of NSAIDs can
lead to ulcers and potentially life-threatening gastric bleeding.
The advantage of the Cox-2 inhibitors is that they target the specific
prostaglandins that cause inflammation without suppressing those
that protect the stomach. The main disadvantage, at least until
now, has been that they are relatively expensivefrom $3 to
$6 a dayand many insurance companies have been reluctant to
pay for them unless patients can demonstrate that they were at high
risk for gastrointestinal bleeding; just being old isnt necessarily
enough.

Arthritis:
the warning signs

If
you have any of these signs in or around a joint for more than
two weeks, see your doctor.
 Pain
 Stiffness
 Swelling (sometimes)
 Difficulty moving a joint

Source:
Arthritis Foundation

Last
week, however, the field was rocked by a paper in The Journal of
the American Medical Association speculating on another downside
to he two drugsa small increase in the risk of cardiovascular
events, including heart attacks and ischemic (clot-related)
strokes. Topol, the author, suspects this is because the drugs promote
the formation of blood clots. But he did not study the two drugs
directly; instead, he analyzed data from existing studies, including
some by the manufacturers themselves. Were not talking
about a panic attack, he said, but a small, quantifiable
risk that needs to be studied.

UNFAIR
COMPARISONS?
Spokesmen for Pharmacia and for Merck (the manufacturer of Vioxx)
were quick to dispute Topols conclusions, pointing to additional
studies that he failed to consider and which, they claim, showed
no added risk from their products. Dr. Steve Geis of Pharmacia says
the company has no evidence that [Celebrex] causes blood clots.
The issue is complicated because some of the studies compared the
Cox-2 drugs with the older class of NSAIDs. At least one of those
compounds, naproxen, is an anticoagulant (like aspirin) which can
reduce the risk of heart attacksmaking for an unfair comparison,
according to Merck. Topol admitted that his tentative conclusions
needed to be tested in clinical trialsbut meanwhile, he strongly
recommends that patients at risk for heart disease take an anticoagulant,
such as low-dosage aspirin, along with a Cox-2 inhibitor. Nobody
with coronary disease ought to be taking these medicines alone,
he told NEWSWEEK. On the other hand, he said, Im not
worried about patients without heart diseaseincluding
himself. Topol has osteoarthritis in both kneeswhich he treats
with occasional doses of either Vioxx or Celebrex, depending on
his need; he finds Vioxxs effects seem to last longer.

At
47, Topol is on the leading edge of what rheumatologists suspect
is a looming epidemic of joint pain. The most obvious fact about
osteoarthritis is that its incidence rises with age. But the increase
appears to set in much earlier than previously believed. Historically,
researchers studied osteoarthritis only in people over 55, but MaryFran
Sowers of the University of Michigan has been studying a cohort
of women between 25 and 55 and found that the average age of onset
for the disease is between 40 and 45. It goes from not being
discerned in the 35-to-40 range to a jump of 8 percent in the 40-to-45
range, and then it jumps again, she said; on average, each
year after the age of 40 sees a 2 percent increase in the rate of
osteoarthritis.

That
epidemiology suggests a regular process, as if joints were simply
wearing out over time. What surgeons see inside arthritic joints
does, indeed, look like wear and tear, particularly on the cartilagethe
rubbery, slippery cushion on the ends of the bones that ordinarily
provides a smooth surface for motion. Damage to the cartilage is
oftenbut not alwaysaccompanied by pain, although researchers
arent even sure exactly why. In the later stages of the disease,
bone rubs and grates excruciatingly on bone. Often the bone sprouts
knobby outgrowths, called spurs. Patients sometimes compare the
pain to a toothache, insistent and deep. The pain will eat
you up eventually. Its there all the time, walking, sitting,
even sleeping, says Brian Hoose, 61, whose arthritic hips,
which he first noticed five years ago, caused him to give up successively
tennis, walking his Russell terriers and eventually, driving. If
you had seen me walking, you would have thought, That guys
90 years old.

UNBENDED
KNEE
Inflammation and swelling often accompany the pain. Tony Evans,
a 51-year-old preacher and the team chaplain for the Dallas Mavericks,
says his arthritic left knee balloons to a size between an
orange and a grapefruit when he plays basketball these days.
When the swelling is at its worst, Evanss doctor has to drain
the fluid around the knee with a syringe. In the most serious cases,
the joint becomes virtually immobilized. Deborah Moraza, who is
only 46, sometimes can barely walk across a room; she carries a
cane in her car and leaves a pair of crutches in her office. She
cannot kneel and sometimes can barely sit; she watches television
stretched out on floor pillows and when she needs to stand, rolls
over onto her front, assumes a push-up position and walks her feet
and hands together, bending at the hipslike a spider,
she says. A spiders knees dont bend and neither
do mine. Recently the pain has spread to her thumbs, meaning
shes had to learn to write all over again: If I hold
my pen like normal people do, I pay the price.

Simple
in concept, on a biomolecular level the deterioration of cartilage
is just the end product of a complex and still-mysterious process.
Cartilage does not, it appears, simply wear out from use over time,
like a piece of fabric. This should be obvious from the fact that
people use both knees at the same rate, but may get arthritis in
only one. It is not a normal part of aging, says Klippel.
The vast majority, even as they age, dont really have
any problems. Although X-rays usually show the telltale narrowing
of cartilage between their bones, most escape without serious symptoms.
Why do some people get the disease and others escape without pain?
A few may be genetically programmed for it, perhaps because of defects
in their production of collagen, the protein that is the structural
component of cartilage. Certain enzymes seem to play a part, and
these may be affected by hormone levels; women are three times more
likely to suffer from osteoarthritis than men. Obesity is a significant
risk factor, which makes intuitive sense; a pound of added body
weight places from two to four pounds extra stress on the
knees and hips during routine movement, estimates University of
Chicago rheumatologist Dr. Michael Ellman. But the actual mechanism
by which cartilage deteriorates under mechanical stress is still
not understood. And, to state the obvious, being fat doesnt
place any added demands on your fingers or elbows.

It
turns out that one of the biggest risk factors is as obvious as
falling down the stairs. Unsophisticated as it sounds, researchers
are coming to appreciate the role of simple joint trauma in the
early development of osteoarthritis. Injuries that seem to heal
perfectly well appear to set up a process of deterioration that
can have devastating effects decades later. In one study, a knee
injury before the age of 22 resulted in a threefold increase in
the incidence of arthritis in the same knee, typically striking
by the mid-50s. Cartilage does not have the ability to repair
itself like other tissues, says Luthra. He draws an analogy
to a car tire, which is supposed to last about 40,000 miles under
normal conditions. But if you drive over glass and the tire
gets cut, its going to wear out faster. Cartilage is made
by nature to last a lifetime,but not if its damaged.
And it isnt only damage directly to the cartilage itself that
causes problems, but also injuries to the ligaments, the elastic
bands of tissue that connect the bones and keep them in alignment.
Torn or stretched ligaments around the weight-bearing joints result
in instability and unnatural stress on bone and cartilage, which
may set off the process of deterioration.

POOR
BIOMECHANICS
Of course, the injury need not be sustained in one cataclysmic episode;
long-term or repeated trauma can have the same effect. This obviously
is the case with many athletes, even those who dont injure
themselves in contact sports. Moraza, the woman whose knees dont
bend, played softball, baseball, tennis, track, basketball, volleyball
and field hockey as a student, and by her 30s had dislocated her
shoulder so often that it would pop out in her sleep. And some people
just have the bad luck to be born with poor biomechanicships
that curve at an unnatural angle, for example. For them, just walking
may set off the process that leads to osteoarthritis down the road.

Yet,
the experts all rush to add, this is not an argument against walking.
On the contrary, low-impact exercise is strongly recommended as
a way to prevent arthritis. Dont think exercise will
cause it, says Dr. Kenneth Cooper, founder of the famed Cooper
Aerobics Center in Dallas. It will aggravate an existing condition.
But in most cases, its going to protect you. Exercise
helps in two ways, by weight reduction and by strengthening the
muscles, which, along with the ligaments, stabilize and support
the joints. Sharon Coyle, a physical therapist who got her first
twinge of arthritis in her right hip at 50, has taken this advice
to heart; at 56, she had a total hip replacement and now, a year
later, she is keeping pain at bay with thrice-weekly water exercises.
When you have arthritis, you have to move, she says.

If
she can hold out, more relief may be on the way. Both Merck and
Pharmacia have second-generation Cox-2 inhibitors in the pipeline,
at least one of which, Pharmacias valdecoxib, may be on the
market by early next year. The companies have said very little about
the new drugs, although industry analysts speculate that they may
have what drug companies call a better safety profile.
(After the stellar launches of Vioxx and Celebrex, sales have shown
signs of leveling off this year, analysts say.) And new techniques
for repairing damaged joints are showing promise. In one, doctors
inject joints with a synthetic derivative of hyaluronic acida
gooey fluid that lubricates normal joints and is lacking in arthritic
ones. The procedure, which has been approved only for knee joints
so far, requires a series of injections costing about $1,200, but
can provide relief for up to a year. Even more impressively, doctors
can now culture cartilage cells in vitro (after harvesting them
from the patients own body) and inject them into a diseased
knee joint, where they multiply and knit themselves into a new matrix
of protective tissue. So far, only patches less than an inch across
have been successfully implanted, so the technique is used more
to repair cartilage damage before full-blown arthritis sets in.

The
ultimate treatment for osteoarthritis is to replace the damaged
joint with an artificial one. The procedure is rapidly growing in
popularity as more patients reach the end of the road with medicine,
and the metal-and-plastic joints become more reliable. Ten years
is considered a minimum life span for a replacement joint and some
last as long as 20. This year American surgeons will perform as
many as 267,000 total knee replacements (more than double the figure
from 1990) and 168,000 artificial hip implants, up by a third from
a decade ago. Brian Hoose got two of them last spring, and six weeks
later he reported that for the first time in years he was able to
sit without pain. Im looking forward to a great 10 years
ahead of me, where before I had no life to look forward to at all.
You get new hips and away you go.

Yes,
thats what we all want: lives free of pain, a chipper old
age, like the happy grandmas playing patty-cake on the TV commercials.
We exercise and we take our supplements and we down our pills and
we hope for the best, like Janiga, the dancer, who accepts the fact
that after six decades of dancing her knees may finally have betrayed
her. I think Im a good example for all the people in
my exercise classes, she says gamely. You have the pain.
You put a smile on your face and you try to be normal.

Arthritis Explained

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